What is lymphedema? Lymphedema occurs when there is infection or blockage of the normal drainage of lymphatic channels from an effected portion of the body. Patients develop swelling of the effected area that is painful and can lead to chronic infection of the tissue. Some common causes of lymphedema are radiation or surgical treatment of cancer. In other cases the lymphedema can arise without and known cause – this is referred to as idiopathic.
What happens when the scrotum is involved in lymphedema? Like involvement of a leg or arm the scrotum swells and in some cases the scrotum can reach an enormous size. The skin of the scrotum is doughy and filled with fluid and becomes thickened and chronically infected. This makes life very difficult for effected patients. Patients often become home bound and have chronic pain associated with the condition.
What can be done for this problem? Surgical management of this problem can work well to return a patients quality of life and restore urination and possibly sexual function. Surgery is done to remove all of the effected tissue and reconstruct the scrotum. In most cases there is enough normal tissue surrounding the scrotum that a scrotal type of appearance can be created. In severe cases of lymphedema of the scrotum, the foreskin of the penis is inverted and the penis is buried in the tissue of the scrotum. Sometimes the tissue of the penis has not been affected by the lymphedema and it can be preserved. In other cases the penile skin is also effected and scarred and needs to be removed. When the penile skin needs to be removed than in some cases a skin graft has to be applied to the penis. This will allow the full length of the penis to be brought out so that the problem with a buried penis is less likely to recur.
What about management of my abdominal fat? It is not totally clear why lymphedema occurs, but it is often in patients with a large belly. Sometimes there is a pannus (a roll of fat) that hangs over the penis and will tend to cause recurrence of the problem with engulfement or burying of the penis. It is best to remove this fat along with the surgery to correct the lymphedema if it is a problem. This surgery is called an abdominoplasty, or a pannicluectomy. Many patients refer to this as a “tummy tuck”. It is done through a long horizontal incision above between the belly button and the penis.
What are some of the complications associated with the surgery? The surgeon has to be very careful about not damaging the penis or the testicles during surgery to remove the scrotum. The penis and testicles are buried in the abnormal tissue and it is easy for a surgeon to seriously damage them during the surgery. A reconstructive urologist can make sure the penis and testicles are carefully preserved during surgery. At University of Utah we have not seen any complications like loss of a testicle or damage to the penis with lymphedema surgery.
What is the post op recovery from the surgery? If a skin graft is needed than patients remain in the hospital for 5-7 days on bedrest to allow the skin graft to fully heal. Otherwise patients may be in the hospital just overnight or for a few days. Patients need to avoid any strenuous physical activity until they are fully healed. We generally recommend they do not lift greater than 15 pounds for a month after the surgery. It is important to have close follow up of the wound to make sure the surgery is healing well. We will generally follow patients every 1-2 weeks after there discharge until the surgery has completely healed. This follow up can be done with an outside urologist in consultation with us anywhere in the country.
Figure 1 – A routine case of scrotal lymphedema
Figure 2 – Operative photo of the reconstructed scrotum and skin graft applied to the penis.